Discussion

I’m a Critical Care Paramedic and I spend 99% of my time in Pediatric Critical Care. We see a lot of pediatric DKA, often presenting with pH as low as 6.8. I can’t speak for the rest of the pediatric world, but in my facility we never use sodium bicarbonate with these patients.
The profound metabolic acidosis in these patients is caused by ketones and lactate. In order to halt the production of ketones and lactate and facilitate their metabolism, the patient must be appropriately fluid resuscitated and started on an IV infusion of insulin (never give kids an IV insulin bolus). It is the insulin and fluids that will clear the acidosis. For profoundly acidotic patients we increase the rate of the insulin infusion and add glucose to the IV fluids if needed. The insulin is what will allow the pH to normalize. NaHCO3 will not help this process and may even hurt.
There is a lot more to treating DKA in kids (and adults) that that. The consensus statement from the ADA below gives a good overview of the initial management of pediatric DKA.
Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. (Diabetes Care. 2006 May;29(5):1150-9.

The acute versus chronic atrial fibrillation exacerbation is a very important topic I often see in the prehospital arena. Paramedics are usually not taught to appreciate this distinction. Was glad to hear the diltiazem slow-drip method was preferred!

I think a future podcast on the acute vs. chronic topic, contrasted to your classic “crashing af patient” podcast, would be very helpful!

The first question about ultrasound guided central lines was a good one and represents a common problem.

Basically there are four ways to use ultrasound to assist in placing venous lines. For all of them you should first do a scan of the area and confirm that the ‘vessel’ you want to cannulate is indeed a vessel, is a vein and is patent. Then you can:
1) blindly access the vein you’ve found
2) as above but with the probe held over the vessel insertion point so that the last part of the needle’s path is visualised, this is Scott and the listener’s technique
3) use out-of-plane needle guidance or,
4) use in-plane needle guidance.

People tend to start with the first two techniques but they’re not reaping the full benefit of ultrasound. Nearly all adult central venous lines (including PICCs) can be done in-plane with real time visualisation of the needle tip through the tissues and real time confirmation of placement in the correct vessel through visualisation of the wire in the vessel. It looks very cool to see your needle tip go the whole way down and your wire come out of the needle tip in the vessel and it impresses bystanders no end. Oh, and it’s safer. Once you learn this technique it will be your default.

The only backup technique you will need is then out-of-plane guidance and the times you might need it are small veins and arteries, for some subclavian lines and on occasion where either the patient or the probe is very large making it hard to get a good in-plane view.

Great show Scott, you see amazing with your commitment and passion for knowledge and education…
I wanted to share in more detail the out plane technique as it did not sound clear cut on the programme if I may please…
Essentially, using US you work out where you want the needle enter the vessel, then back off some distance and make the entry point into the skin still some distance away and perpendicular to the axis of the probe, hold the probe steady until you see the echogenic tip of the needle on the screen.. From there, slide the probe along the vessel 1-2mm and advance the needle again until you see the echogenic tip on the screen. Continue until you are in the vessel. So you sort of move one step at a time.
Another way of doing it, albeit more fiddly in the beginning, is once you have got the tip of the needle on the screen advance the needle and slide the probe simultaneously. This way requires a fair bit of practice as both hands need to move in sync.
Both techniques work equally well for central and peripheral lines.
Thanks for your attention.

Agree and thanks for writing these down here. This is exactly how I put in peripheral IVs. Only problem with this in the neck is that the spot of entry of the needle into the vessel may not be as favorable an anatomy as where you started the skin entry. SO if you go in this direction, I would recommend scanning a few inches down on the IJ before you start to make sure the vessel is big in its entire length so that when the needle is actually about to hit the IJ, there is a clear path into a big vessel.

Probably not the best place to put a request in, my apologies before hand. Could you please share in one of your podcasts some pearls on central line /artline placement in cardiac arrest/CPR. With CVC it is probably easier as you can just go IO. I vaguely recall you talking about it in your earlier podcasts, but there was nothing specific in detail. specifically at what point in time you would start seriously thinking about it and how hung up on it (I.e. how obsessed with it) would you be. Thanks.

the only tip at this stage is probably not to do it. it is dangerous and leads to needle sticks and patient trauma. wait till the patient gets a pulse. Meds prob. don’t do much, so obsess about good CPR instead of access.

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